What does SOAP stand for in therapy notes?

SOAP stands for Subjective, Objective, Assessment, and Plan. It is the most widely used clinical documentation format across medicine and behavioral health, originating in the 1970s problem-oriented medical record (POMR) movement. The four-part structure separates patient-reported information, observable data, the clinician's clinical reasoning, and the next steps.

What goes in the Subjective section of a SOAP note?

Patient-reported information: what the patient said about their mood, symptoms, recent events, sleep, appetite, stressors, side effects, and goals. Direct quotations are common (e.g., 'I've been crying every day'). The chief complaint, history of present illness updates, and any reported scale interpretations from the patient's perspective also belong here.

What goes in the Objective section of a SOAP note?

Observable data: mental status exam findings, behavioral observations (eye contact, psychomotor activity, affect), validated scale scores (PHQ-9, GAD-7, PCL-5), test results, vital signs if measured, and reports from collateral sources. The Objective section should describe what was measured or observed, not interpreted.

What goes in the Assessment section of a SOAP note?

Clinical interpretation: the clinician's synthesis of the Subjective and Objective data into a clinical picture. Includes ICD-11 diagnosis (or differential), severity assessment, scale interpretation in context, change from prior visits, comorbidities, and treatment response evaluation. This is where you reason from the data toward clinical decisions.

What goes in the Plan section of a SOAP note?

What's next: treatment recommendations, medication adjustments, therapeutic interventions to deploy, frequency of follow-up, referrals, scales to readminister, between-session homework, and any urgent action steps (safety planning, crisis resources). Each item should be specific enough that another clinician could continue care from your note alone.

What is an example of a SOAP note for therapy?

S: Patient reports persistent low mood for 3 weeks, sleep onset latency 2 hours, lost interest in usual hobbies. O: PHQ-9 score 16 (moderately severe), affect constricted, eye contact appropriate, no SI. A: F33.1 Major Depressive Disorder, Recurrent, Moderate, current episode partially responsive to sertraline 100mg. P: Continue sertraline; add behavioral activation worksheet; readminister PHQ-9 next session; follow up in 1 week.

How is a SOAP note different from a DAP note?

SOAP separates Subjective (what the patient reports) from Objective (what the clinician observes and measures), then proceeds to Assessment and Plan. DAP collapses Subjective and Objective into a single Data section. SOAP is preferred in multi-disciplinary settings, payer-friendly defaults, and presentations where the gap between self-report and observation is diagnostically meaningful. DAP is faster to write and common in private practice and outpatient psychotherapy.

When should I use a SOAP note in mental health practice?

SOAP is the safest default across U.S. behavioral health settings because it is the most familiar format to payers, auditors, and other treating clinicians. Use SOAP for medication management visits, intake evaluations, psychotherapy sessions in multi-disciplinary clinics, and any context where claims may be audited. Choose BIRP when interventions are the audit focus (case management, IOP) or DAP when private-practice efficiency outweighs the structural detail.

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Date: 2026-04-24 Time: 14:00–14:45 (45 min, 90834) Diagnosis: F33.1 Major Depressive Disorder, Recurrent, Moderate Patient: J.D., established, age 34 S: Subjective Patient reports mood "still pretty low most days but maybe a notch better than last visit." Sleep improved, averaging 6–7 hours from prior 4–5. Appetite normal. Denies SI. Reports starting morning walks 3×/week. Med tolerance good. No GI side effects on sertraline 100 mg. O: Objective PHQ-9 administered: 12 (down from 16 at last visit). GAD-7: 8 (down from 11). Affect: mildly constricted but more reactive than prior. Speech: normal rate, prosody. MSE: alert, oriented ×3. Insight and judgment intact. No suicidal ideation, plan, or intent. A: Assessment F33.1 in active treatment, showing clinically meaningful improvement (PHQ-9 -4 points). Comorbid F41.1 (GAD) also responsive. Activation behaviors (morning walks) consistent with behavioral activation strategy. No medication adverse effects to address. Risk: low. Item 9 negative, no recent ideation. P: Plan Continue sertraline 100 mg. Continue weekly behavioral-activation focused CBT. Reinforce activity scheduling. Re-administer PHQ-9 + GAD-7 at next visit (2026-05-01). Discussed sleep hygiene strategies. Patient to track activation goals between sessions. CPT: 90834 + 96127×2 (PHQ-9 + GAD-7)

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Date: ____ Time: ____ – ____ (___ min, CPT ____) Diagnosis: ____ (ICD-11) Patient: ____, ____ session S: Subjective [Patient-reported mood, symptoms, sleep, appetite, stressors, side effects, goals. Direct quotations welcome.] O: Objective [Mental status exam findings. Scale scores: PHQ-9 ___, GAD-7 ___, PCL-5 ___, AUDIT ___ (whichever administered). Behavioral observations.] A: Assessment [Clinical interpretation of S + O. Diagnosis confirmation or update. Severity, change from prior, treatment response. Risk assessment if relevant.] P: Plan [Interventions, medication changes, frequency, referrals, scales to re-administer, between-session tasks, safety planning.] CPT: ____ + 96127×__ (scales administered)

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Sources & Citations

1.
Weed, L. L. (1968). Medical records that guide and teach. New England Journal of Medicine, 278(11), 593–600.
2.
U.S. Department of Health & Human Services. HIPAA Privacy Rule and Sharing Information Related to Mental Health.
3.
American Medical Association. Current Procedural Terminology (CPT) 2026, code 96127 documentation requirements.

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